Orthotics in Rheumatoid Arthritis Save

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting synovial joints, often in the hands and feet. Due to its progressive inflammatory nature, RA can lead to impairment of function, reduced quality of life, significant joint pain, disability, and deformities. As a result, interventions to manage pain, loss of function, and quality of life are critical.

Orthotics are cost-effective, externally applied devices designed to stabilize the joints and provide a conservative measure to alleviate joint pain and improve function.

Orthotic options include therapeutic shoes, shoe inserts, hand splints/braces, wrist support and finger splints. Orthotics are an important part of multidisciplinary management of the RA patient. This article reviews some of the indications on the use of orthotics in patients with RA.

Lower extremity orthotics

The lower extremity orthotics recommended in patients with RA include therapeutic shoes, inserts and insoles.  Stabilizing the foot and correcting weight bearing can potentially benefit patient outcomes (Woodburn et al., 2002). Therapeutic shoes are designed to reduce plantar pressure and stabilize the foot/ankle, thereby decreasing pain and improving gait. Therapeutic shoes include both ready-made shoes with extra depth and support as well as custom-made shoes tailored based on the individual’s needs, functional level, and specific measures (Tenten‐Diepenmaat et al., 2018). Foot orthotics are shoe inserts used to correct ankle malalignments and reduce pain and swelling.

Multiple studies have been conducted to evaluate lower extremity orthotics in RA. A systematic review and meta-analysis by Tenten‐Diepenmaat et al. in 2018 summarized the literature on the use of therapeutic shoes in RA and reported overall improvement in physical function and reduction in foot pain. However, the review failed to show significant changes in the health-related quality of life measures.  It was concluded that more adequately powered randomized controlled trials are required to accurately evaluate the effectiveness of therapeutic shoes and their impact on the quality of life. One randomized controlled trial that was not included in this review showed that a 30-month use of custom manufactured foot orthotics in RA resulted in reduction in foot pain by 19.1%, functional limitation by 13.5%, and foot disability by 30.8% (Woodburn et al., 2002).  Health-related quality of life measures were not included in this study.

Another study showed that four-weeks of custom-made foot orthotics reduced foot and ankle pain, by altering ankle joint mechanics (Simonsen et al., 2022). In this study, the foot orthotics were customized based on the plantar geometry of the medial longitudinal arch height and contour of each patient. In another qualitative study, patients with RA reported improvement in physical function, general wellness, and quality of life after wearing orthotics for six months. In the same study, patients stated that these benefits were achieved with suitable footwear and a proper fit to accommodate both the foot and the insole (Ramos-Petersen, et al. 2021). However, finding suitable footwear may be challenging for some patients.

There are multiple factors involved in the suitability of these devices. Some of these factors include patient’s foot size relative to the shoe size, the width of the toe box, the depth and shape of the shoe to accommodate patient’s foot shape and arch type. The materials that make up these devices can also play a role in comfort and ease of use. Different materials such as plastic, rubber, foam, leathers, or synthetic fabrics offer varying levels of comfort, flexibility, and support. Another important factor to consider is the patient’s activity level. Patients who are highly active and are runners require proper foot cushioning, whereas walking shoes require good stability.

The lower extremity orthotics can be obtained over the counter and through online retailers. However, for optimal fit, comfort and suitability, these devices should ideally be procured through podiatrists and/or orthotic specialists. These specialists take 3D measurements of the lower extremity and design custom orthotics tailored to these measurements and the individual’s needs. They also work with the patient to use materials that provide enhanced ease of use based on testing different movements and range of motion of the lower extremity. Patients should also be referred to physical therapists and occupational therapists for activities that help achieve optimal use of the devices.

Upper Extremity Orthotics

Upper extremity orthotics in RA include resting hand braces/splints, wrist support/splints, and static or dynamic finger splints. There may be rigid, semi-rigid, or soft/flexible orthotics often procured from orthotic specialists, occupational therapists or upper extremity orthopedists. 

Upper extremity orthotics are designed to provide joint stability, prevent contractures, and reduce pain and swelling by spreading the forces over larger areas and allowing the joints to operate at an improved range of motion. Wrist orthotics are prescribed with the goal of reducing pain and inflammation through supporting the wrist joint and restricting its motion while allowing fingers to move freely. It is recommended that RA patients should wear wrist orthotics for activities that are likely to cause stress to the wrist, such as heavy lifting or high resistance movements.

There is a lack of high-quality data on the impact of these orthotics on pain and quality of life. There are a few studies that have shown positive results, whereas others have failed to demonstrate significant differences with the control group. A multi-center, cross-sectional study showed that more than 50% of RA patients own wrist orthotics, but only 58% use them (de Boer et al., 2008). These devices are most useful for those who have active symptoms and poor functional ability, as opposed to those who have been prescribed for preventive purposes.  Therefore, the presence of symptoms and functional limitations are important factors for usage. Improvement in pain has been reported as the main positive impact of use. However, adverse effects, such as restricted range of motion, decreased dexterity, and lack of user friendliness of the devices have also been reported as barriers of use. Therefore, continued improvement in the design of such devices is crucial to ensure ease of use, comfort, and compliance.

Conclusion

This article provided a brief overview of the utility of orthotics in RA. Foot, wrist and hand orthotics can be helpful for pain relief, joint stabilization, and function improvement in patients with RA. More research is required to identify optimal candidates for orthotics, with attention on user friendliness and comfort without compromising range of motion and dexterity.

References

1. de Boer IG, Peeters AJ, Ronday HK, Mertens BJ, Breedveld FC, Vliet Vlieland TP. The usage of functional wrist orthoses in patients with rheumatoid arthritis. Disabil Rehabil. 2008;30(4):286-95. doi: 10.1080/09638280701257031. PMID: 17852215.
2. Ramos-Petersen L, Nester CJ, Ortega-Avila AB, Skidmore S, Gijon-Nogueron G. A qualitative study exploring the experiences and perceptions of patients with rheumatoid arthritis before and after wearing foot orthoses for 6 months. Health Soc Care Community. 2021 May;29(3):829-836. doi: 10.1111/hsc.13316. Epub 2021 Feb 9. PMID: 33560583.
3. Simonsen MB, Næsborg-Andersen K, Leutscher PDC, Hørslev-Petersen K, Woodburn J, Andersen MS, Hirata RP. The effect of foot orthoses on gait biomechanics and pain among people with rheumatoid arthritis: A quasi-experimental study. Gait Posture. 2022 Jun;95:121-128. doi: 10.1016/j.gaitpost.2022.04.016. Epub 2022 Apr 19. PMID: 35487019.
4. Tenten-Diepenmaat M, van der Leeden M, Vliet Vlieland TPM, Roorda LD, Dekker J. The effectiveness of therapeutic shoes in patients with rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol Int. 2018 May;38(5):749-762. doi: 10.1007/s00296-018-4014-4. Epub 2018. PMID: 29556705.
5. Woodburn J, Barker S, Helliwell PS. A randomized controlled trial of foot orthoses in rheumatoid arthritis. J Rheumatol. 2002;29(7):1377–1383.